Stop the Blame Game: Restructuring Morbidity and Mortality Conferences to Teach Patient Safety and Quality Improvement to Residents

Abstract

Introduction: Adverse events leading to patient harm are rarely the result of an individual error but are instead due to a series of errors resulting from system breakdowns. Thus, the Accreditation Council for Graduate Medical Education requires all residents to participate in quality improvement and patient safety programs. However, a major reported obstacle to sustainable quality improvement and patient safety curricula, as well as meaningful practice improvement, is the small number of faculty with expertise or training in these topics.

Methods: This workshop provides a simple framework for redesigning traditional morbidity and mortality conferences for faculty who have minimal quality improvement training. The materials associated with this publication include a standardized presentation template, sample teaching points, and a faculty facilitator's guide.

Results: Between August 2014 and February 2015, 135 trainees from one of our tertiary training sites attended seven of these redesigned conferences. The largest gains were made in teaching residents how to use a systems-based approach to analyze medical error and how to identify corresponding error-reduction strategies. Residents also perceived themselves as more likely to put their knowledge into action through filing an incident report after attending the conference. The one item that did not change was the residents' perception of safety culture at their institution, suggesting that attendance at a monthly conference is not sufficient to change culture.

Discussion: Similarly formatted M&Mconferences may help institutions address several aspectof the ACGME CLER program that provides programswith periodic feedback regarding trainee education onpatient safety and quality improvement as well.

Keywords: Morbidity and Mortality; Patient Safety; Quality Improvement; Systems Theory.